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Item <br />f <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />T Date: `C6 /7- O S <br />Name: C.&Y <br />Address: 701 E G HA r GW - <br />Zi2 Code: o <br />cS Glc Y - D �9) <br />ted UST O for Conductin the Ins tion: A Fx iration �A� <br />ional Code Council Certification #: J ?47 5l -Ur: Phone: o?s N a Na NA = Not App licable <br />MONITORING PANEL /ALARM HISTORY Y N I NA <br />1 Monitorin stem is wered on and in propero ratin mode. <br />2 Monitorin system is not currentlyshowingan alarms or warnin s. ✓ <br />3 Alarm history report/log for the previous month is available, and has been reviewed by the <br />Desi aced UST razor. Attach a co o the alarm histo re ort/lo to this orm i available. <br />4, Each alarm for the previous month has been responded to a ro riatel . <br />5 Sensors located in tank -to containment sum s have not alarmed in the t month. <br />5a - List all tank -top sumps where alarms occurred in the past month: <br />t month must be inspected unless a qualified service technician responded to, and <br />Note: Sumps where an alarm has occurred in the pasthe alarm. Attach documentation verifying appropriate service to this report. <br />properly addressed the cause o j <br />1 sum i------ ;__ is re wired record results in item 6, below. <br />UST SYSTEM INSPECTION <br />6 Tanker p ca ntainment sumpsrarnlfreetof water, deb/risc brad/ha�zardousav acc s ebstaheeaSmonth r whi located <br />here is no properly. <br />It <br />N Y N <br />Y <br />Sum Location: <br />Sum Location: 1,WZC Sum Location: <br />Sum Location: Rt-'M1';"f Sum Location: <br />Sum Location: <br />7 S ill containment structures are free of water, debris, and hazardous substance- N NA <br />Y N NA Y <br />Tank 3 -Contents: <br />Tank 1 -Contents: L1M�tyte'ED Tank 4 - Contents: <br />Tank 2 -Contents: 2u>Nl�r� <br />8 Under�is user containment areas are free of water, debris, and hazardous substance. Sensors are located rN r NA <br />Y N NA Y <br />112 Dis user 9 / 10 <br />Dis eraser 11 / 12 <br />314 Dis enser 13 / 14 <br />5/6 Dis enser15/16 <br />7/8 <br />D <br />PAPERWORK INSPECTION Y N NA ATE DONE <br />6-L- O`t <br />9 Monitorin stem certification has been com leted wlthm t 12 months. 2 -o <br />10 Secon containment tests have been com leted within the utred timeframe. _ <br />11 S ill containment structure ucket testin was co m leted within the ast ear. ✓ _ 1 _ o <br />12 Tank ti tness testis was completed within uired timeframe' _ _ 04 <br />13 Line ti mess testis was com leted within aired timeframe. <br />testis maintenance was completed within <br />required timeframe•�isist/maintenance items below. <br />14 Other �Q -2-2-09 <br />Test/Maintenance: ��T J_ <br />- o <br />Test/Maintenance: ArLi `^ ie*- November 2004 <br />Page 1 of 2 — <br />